MEDICARE: MIRANDA PHYSICAL THERAPY LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QP2000X	Physical Therapy Clinic/Center	5061	AZ

General Provider Information

NPI Number	:	1134304314
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MIRANDA PHYSICAL THERAPY LLC

Provider Business Mailing Address
First Line	:	5815 N. BLACK CYN HWY
Second Line	:	100
City	:	PHOENIX
State	:	AZ
Zip	:	85015-2200
Country	:	US
Telephone Number	:	602-249-0607
Fax Number	:	602-249-0741

Provider Business Practice Location Address
First Line	:	5815 N. BLACK CYN HWY
Second Line	:	100
City	:	PHOENIX
State	:	AZ
Zip	:	85015-2200
Country	:	US
Telephone Number	:	602-249-0607
Fax Number	:	602-249-0741

Authorized Official
Title or Position	:	OWNER
Name	:	MR. DAVID AARON MIRANDA
Credential	:	MPT
Telephone Number	:	602-249-0607

Provider Enumeration Date	:	01/07/2008
Last Update Date	:	10/11/2011

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